Analysis Sinking of the Vessel Although the precise cause of the sinking could not be determined, it is likely that the wiring of the one serviceable pump became disconnected, or else that the pump was unable to keep up with the ever-increasing rate of water ingress through the stuffing box. In addition, because the batteries were mounted on the bottom of the bilge, they likely would have become immersed in water and possibly short-circuited the power early on in the flooding process. With no power, the vessel's VHF radiotelephone, cellular telephone, and only operating bilge pump would have been unusable. High Level Bilge Alarms Being a small fishing vessel, the Lannie & Sisters II was not required to have a high level bilge alarm installed, nor was there one installed. As a result, the crew received no warning of water ingress. Previous TSB reports have recognized the dangers associated with not having such an alarm.4 The Workers' Compensation Board of British Columbia requires all commercial fishers to install a high water level detector in the engine compartment and lazarette of their vessel, and to have these connected to an alarm system.5 A high level bilge alarm, if fitted, would have given the delivery crew early warning that the bilge pump was not performing adequately. Under the proposed regulations pursuant to Canada Shipping Act, 2001 reforms, the Lannie & Sisters II would have been required to have such a device. Safety Equipment There was no liferaft or recovery boat on board the Lannie & Sisters II at the time of the occurrence, nor was this required by regulations. Although the captain possessed an immersion suit, there were none on board when the delivery crew took over. Because the vessel routinely went beyond 25 nm from shore, under the proposed Fishing Vessel Safety Regulations, it would have been required to carry a liferaft or recovery boat. The 12 expired flares on board were stowed in a cabinet under the steering console in a non- watertight container. The delivery crew was not made aware of their whereabouts before departure and their whereabouts were such that locating them would have been difficult. The flares were found undisturbed after recovery of the vessel. The firing of flares could have contributed to an earlier notification of distress. Although the Lannie & Sisters II was not required to carry an EPIRB, the carriage of one would have provided an opportunity to automatically initiate a transmission and to alert SAR authorities at the onset of the distress, increasing the chances of survival. Under proposed reforms to the Canada Shipping Act, a vessel on a voyage outside 25 nm will require an EPIRB. Safety Culture and Shared Responsibility for Safety It is the duty of every owner and captain to ensure that each vessel is safe to go to sea. Despite the owner's and fishing crews' experience in the fishing industry, the characteristics of the vessel indicated a lack of awareness of or compliance with marine standards of safe construction and maintenance. Although the owner of the Lannie & Sisters II realized that there was still an ingress of water from the stuffing box, no arrangements were made to have it repaired. The bilge pumping system was not maintained to a level where it was reliable or, on the day of the occurrence, even serviceable. A bilge pumping system is designed to handle small leaks and incidental water ingress, but is not considered a damage-control system. The fishing crew was aware of the leak and had brought the subject up to the owner on several occasions. Tentative plans were made to haul the vessel out of the water for the necessary repairs, but these had not yet been realized. Before departure on the morning of the occurrence, neither the owner nor the delivery crew ensured that the basic lifesaving equipment was on board. The delivery crew had limited familiarity with the vessel. The owner of a vessel has a responsibility to familiarize any new captain and crew members with the layout and safety equipment of that vessel. Whether the delivery crew was aware of the vessel's condition and lack of safety equipment is unknown, but the fact that the vessel left the dock without ensuring that the minimal safety equipment required was on board indicates a lack of preparedness and risk assessment. Following the major water ingress on the Alex B. 1, off Havre-Saint-Pierre, Quebec, on 29September 2001, the TSB, recognizing the need for a safety culture in the Canadian fishing industry, issued the following recommendation: As of November 2006, TC advised that, following consultations with a variety of associated organizations, a Memorandum of Understanding (MOU) has been signed by TC and the Department of Fisheries and Oceans (DFO), providing a mechanism for coordinating the development of a number of strategies to promote safety within the fishing industry. However, as of February2007, the action was deemed not yet sufficiently advanced to reduce associated risks, and the Board rated the response as "satisfactory intent." With the coming into force of the Canada Shipping Act, 2001 on 01July 2007, a TC "backgrounder"7 included the following under the title "Developing a Safety Culture Within the Marine Industry": It is the TSB's experience that unsafe practices as outlined in this occurrence are not uncommon on small fishing vessels and can be due to a combination of reasons, including the absence of a safety culture, misperception of risk, and a lack of awareness. Common remarks among fishers following an accident they have survived are that they have previously experienced far worse conditions on numerous occasions, and have not feared for their safety. This type of rationalization can be dangerous because the expectation of success is increased with the completion of each voyage. As a person becomes more complacent, the threshold of risk grows and can lead to additional unsafe practices.8 In this occurrence, the delivery captain was an experienced fisherman and may likely have seen little risk in the short voyage in good weather. While attitudes toward personal safety among many fishers are improving, there remains a segment that is willing to accept the risks associated with fishing and the manner in which it has been carried out over the years. Neither crew member had MED training, currently available, but which was not mandatory until 01April 2008. Although MED courses can be considered a bare minimum for surviving a distress situation, safety training tends to change fishers' perceptions of risk by increasing the awareness of certain kinds of those risks.9 Regulatory Oversight The Lannie & Sisters II, as a vessel with a gross tonnage under 15, was not required to be inspected by TC. Under the proposed reforms to the Canada Shipping Act (Canada Shipping Act, 2001), the proposed Fishing Vessel Safety Regulations would see vessels of this class undergo an initial inspection. These vessels would also require an annual self-inspection. An initial inspection by TC or a cursory self-inspection would have identified safety hazards on board the Lannie & Sisters II such as the bilge pumping arrangements and wiring. A TC inspection would also likely have identified any missing or outdated lifesaving equipment. Similar provisions are currently being applied to other small commercial vessels that do not require an annual TC inspection. For example, under TC's Small Vessel Monitoring & Inspection Program (SVMIP), passenger vessels less than 15 tons are required to have an initial inspection before entering service, and are encouraged to carry out regular self-inspections. The SVMIP does not apply to small fishing vessels. Due to inadequate maintenance and upkeep of the stuffing box, the vessel likely experienced a steady ingress of water, and eventually foundered. The lack of a high level bilge alarm deprived the delivery crew of an early warning that the bilge pump was not performing adequately. The installation and maintenance of bilge pumps was such that they were either unreliable or unserviceable. The batteries were located where rising water levels would have quickly covered them, thereby disabling both the means of communication and the only working bilge pump. There were no immersion suits, lifejackets, personal flotation devices, liferafts, or boat on board to provide the crew with flotation or protection from the elements in the event of an abandonment. A probable lack of awareness of the flares' condition and location likely deprived the delivery crew of a possible distress signal, thereby reducing the chance of rescue.Findings as to Causes and Contributing Factors Due to inadequate maintenance and upkeep of the stuffing box, the vessel likely experienced a steady ingress of water, and eventually foundered. The lack of a high level bilge alarm deprived the delivery crew of an early warning that the bilge pump was not performing adequately. The installation and maintenance of bilge pumps was such that they were either unreliable or unserviceable. The batteries were located where rising water levels would have quickly covered them, thereby disabling both the means of communication and the only working bilge pump. There were no immersion suits, lifejackets, personal flotation devices, liferafts, or boat on board to provide the crew with flotation or protection from the elements in the event of an abandonment. A probable lack of awareness of the flares' condition and location likely deprived the delivery crew of a possible distress signal, thereby reducing the chance of rescue. Lack of a mandated vessel inspection regime likely prevented maintenance issues from being noticed and acted upon by inspectors. The delivery crew members' limited familiarity with the vessel's operation, combined with their lack of marine safety training, may have negatively affected their appreciation of the risks involved. Despite efforts to correct the situation, the lack of a safety culture in the fishing industry continues to put fishing vessels and their crews at risk.Findings as to Risk Lack of a mandated vessel inspection regime likely prevented maintenance issues from being noticed and acted upon by inspectors. The delivery crew members' limited familiarity with the vessel's operation, combined with their lack of marine safety training, may have negatively affected their appreciation of the risks involved. Despite efforts to correct the situation, the lack of a safety culture in the fishing industry continues to put fishing vessels and their crews at risk. Safety Action Taken Marine Personnel Regulations In the Marine Personnel Regulations of the Canada Shipping Act, 2001, Transport Canada introduced a requirement for masters of fishing vessels of less than 15 gross tons, operating more than two miles from shore, to have successfully completed at least Small Vessel Operator Proficiency training no later than 07 November 2015.